`A4363` Ostomy clamp, replacement

Ostomy clamp, any type, replacement only, each

Medicare coverage: Special coverage instructions apply
Status: active (October 2026 file)

Medically Unlikely Edits (effective October 1, 2026)

Practitioner: max 1 units per day (clinical), rationale: Clinical: Data
Outpatient hospital: max 0 units per day (clinical), rationale: CMS Policy
DME supplier: max 6 units per day (clinical), rationale: Clinical: Data

Medicare pricing for A4363

DMEPOS fee schedule, July 2026 (DME26-C)

no modifier, ostomy, tracheostomy and urological (OS): non-rural $2.87 to $3.38 in the contiguous states; $2.21 to $2.87 in AK, HI, PR and VI; ceiling $3.38, floor $2.87

Physician Fee Schedule (CY 2026, RVU26D)

Status X: statutory exclusion, not paid under the PFS.

Payer policies and prior authorization for A4363

Payer coverage policies that name A4363

A4363 appears in 1 coverage policy from Aetna.

Payer	Policy	Role in policy	Reviewed	Document
Aetna	Ostomy Supplies (0906)	covered if criteria are met	Dec 22, 2025	payer document

Medicaid fee-for-service

Prior authorization required or conditional in KY, MA, NY, OH, VA.

AZ: $3.77 (dme), effective Oct 1, 2026
CO: $2.32 (chp_plus, non-facility), effective Jul 1, 2026
FL: $4.45 (dme), effective Jul 1, 2026
IL: $2.92 (dme), effective Jan 1, 2026
IN: $2.01 (professional, Advanced Practice Nurse (85%), non-facility), effective Jan 1, 2014
KS: $2.70 (default), effective Jul 1, 2026
KY: $2.01 (dme), effective Jan 1, 2026
MA: $2.75 (dme_rates), effective Mar 1, 2026
MD: $2.87 (dme), effective Apr 1, 2026
MS: $2.30 (comprehensive), effective Jul 1, 2026
ND: $0.00 (dme), effective Aug 1, 2026
NE: $2.50 (dme), effective Jul 1, 2026
NY: $1.83 (dme), effective Jul 1, 2026
OH: $2.64 (dme), effective Jan 1, 2026
OK: $2.87 (dme), effective Jan 1, 2026
TX: $2.17 (dmepos_tos_9_e_j_l_and_r, Home Health Dme, non-facility), effective Mar 1, 2012
VA: $2.58 (dme), effective Dec 1, 2026
VT: $2.40 (outpatient_hospital_opps), effective Feb 1, 2026
WA: $2.54 (medical_equipment_supplies), effective Jul 1, 2026
WY: $0.00 (outpatient_hospital_apc, Children's Hospitals), effective Apr 1, 2026

From payers' published prior-auth lists, coverage policies and state Medicaid fee schedules, updated Oct 16, 2026. The role is what the policy's own code table or text says about the code. Not a guarantee of coverage or payment; verify with the payer. CPT® is a registered trademark of the American Medical Association.

A4363 Ostomy clamp, replacement